Reid Garrett, Rauh Jessica L, Wood Elizabeth, Dantes Goeto, Santore Matthew T, Wallace Marshall W, Zamora Irving J, Collings Amelia, Callier Kylie, Slater Bethany J, Krinock Derek, Siddiqui Sabina, Vandewalle Robert, Witte Amanda, Flynn-O-Brien Katherine, Patwardhan Utsav M, Ignacio Romeo C, Knod Jennifer Leslie, Dukleska Katerina, Livingston Michael H, Scholz Stefan, Bosley Maggie, Neff Lucas, Alemayehu Hanna
Wake Forest School of Medicine, Winston Salem, USA.
Wake Forest School of Medicine, Winston Salem, USA.
J Pediatr Surg. 2025 Jan;60(1):161959. doi: 10.1016/j.jpedsurg.2024.161959. Epub 2024 Sep 24.
Choledocholithiasis in children is commonly managed with an "endoscopy-first" (EF) strategy (endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC)). Because ERCP availability is often limited at the end of the week (EoW), we hypothesized that a "surgery-first" (SF) approach (LC with intraoperative cholangiogram (IOC) ± transcystic laparoscopic common bile exploration (LCBDE)) would decrease length of stay (LOS) and time to definitive intervention (TTDI).
A multicenter, retrospective cohort study was conducted on pediatric patients from 2018 to 2023 with suspected choledocholithiasis. Work week (WW) presentation was defined as admission between Monday to Thursday. TTDI was defined as time to LC or postoperative ERCP (if required).
Among seven hospitals, there were 354 pediatric patients; 217 (61%) managed with SF (125 WW, 92 EoW) and 137 (39%) managed with EF (74 WW, 63 EoW). SF groups had a shorter LOS for both WW and EoW presentation (60.2 h and 58.3 h vs 88.5 h and 93.6 h respectively; p < 0.05). TTDI decreased in SF (26.4 h and 28.9 h vs 61.4 h and 72.8 h; p < 0.05). All EF patients underwent at least two anesthetics (preoperative ERCP followed by LC) while the majority (79%) of the SF group had only one procedure (LC + IOC ± LCBDE).
Children who present with choledocholithiasis at EoW have a longer LOS and TTDI. These findings are amplified when children enter an EF pathway. A surgery-first approach results in fewer procedures, decreased TTDI, and shorter LOS, regardless of the time of presentation.
Level III.
儿童胆总管结石通常采用“内镜优先”（EF）策略进行治疗（内镜逆行胰胆管造影术（ERCP）后行腹腔镜胆囊切除术（LC））。由于周末（EoW）时ERCP的可及性往往有限，我们推测“手术优先”（SF）方法（术中胆管造影（IOC）的LC±经胆囊腹腔镜胆总管探查术（LCBDE））会缩短住院时间（LOS）和确定性干预时间（TTDI）。
对2018年至2023年疑似胆总管结石的儿科患者进行了一项多中心回顾性队列研究。工作日（WW）就诊定义为周一至周四入院。TTDI定义为至LC或术后ERCP（如有需要）的时间。
在七家医院中，有354例儿科患者；217例（61%）采用SF治疗（125例WW，92例EoW），137例（39%）采用EF治疗（74例WW，63例EoW）。SF组在WW和EoW就诊时的LOS均较短（分别为60.2小时和58.3小时，而88.5小时和93.6小时；p<0.05）。SF组的TTDI缩短（26.4小时和28.9小时，而61.4小时和72.8小时；p<0.05）。所有EF患者至少接受了两次麻醉（术前ERCP后行LC），而SF组的大多数（79%）患者仅进行了一次手术（LC+IOC±LCBDE）。
在EoW出现胆总管结石的儿童LOS和TTDI更长。当儿童进入EF治疗路径时，这些结果会更明显。无论就诊时间如何，手术优先方法可减少手术次数，缩短TTDI并缩短LOS。
三级。
